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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315002322
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:39:24 PM


Document Has Been Signed on 05/23/2024 03:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:WESTWOOD HILLS SENIOR CARE HOMEFACILITY NUMBER:
315002322
ADMINISTRATOR:LISNAWATI, SHAINAFACILITY TYPE:
740
ADDRESS:521 SILKWOOD DRIVETELEPHONE:
(530) 210-6183
CITY:AUBURNSTATE: CAZIP CODE:
95603
CAPACITY:6CENSUS: 5DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Shaina LisnawatiTIME COMPLETED:
05:00 PM
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On 5/23/2024 LPA Tryon visited the facility to conduct an annual visit using the CARE Tool. LPA met with Shaina Lisnawati and Francisca Ingegneri.

LPA toured the facility including common areas, dining area, bedrooms, bathrooms, laundry room, kitchen, and Yard.

The home appears to be well-furnished, clean, and in good repair. Food supplies are adequate to meet the requirement of 2 days perishable and 7 days non-perishable supplies and of good quality and variety. The facility has adequate supplies of PPE, cleaners, etc. Smoke detectors installed and functioning, fire extinguisher present and charged, carbon monoxide detectors installed.

Medications are centrally stored, locked and logged. Cleaners, potentially hazardous items and substances are secured.

LPA reviewed 2 staff files and 2 of 5 resident files. Files appear to include appropriate documentation.

LPA interview one staff person. Residents have dementia; no resident interview conducted.

LPA reviewed the CARE Tool with staff.

The facility appears to be in substantial compliance with the regulations at this time. No deficiencies were cited at this visit.

Exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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